Beruflich Dokumente
Kultur Dokumente
INTERVIEWER: ______________________
Please legibly print the following Nutrition Information. This form is crucial in developing an
appropriate treatment plan for you. Please answer the questions as completely as possible. Thanks!
Name: Date:
Height: _________ Weight: _________lbs. Highest Weight? _______lbs. When? ________ BMI:
_____
Confidential, 1
Did you receive any Diabetes Diet Controlled Yes No
Education? Yes No Oral Medications Yes No
Insulin Yes No
Artificial Type:
Sweetener
Carbonated Yes How much? Type?
Drinks & Soda No
Indicate Family Medical History: (please check box)
Mother Father Brother( Sister(s) Dietitian/ Nutritionist Notes
s)
Confidential, 2
Describe your weight
at high school
graduation:
Describe your weight
during your 20’s
What do you attribute your weight gain to?
How long have you
been obese?
___________yrs.
What are you
currently doing to
lose weight?
How long have you
been at your current
weight?
Do you now, or in the Yes No If yes, please describe.
past, binge on food?
Do you have a history Anorexia Excessive Laxative Use
of the following? Bulimia Diuretics Use for weight control
Do you now or in the Yes No If yes, please describe.
past have any history
of purging on food?
What dieting Phen Fen Pondamin Fastin Dexatrim Meridia
prescription drugs or Metabolife Atipex Xenical Diuretics Amphetamines
over the counter drugs Redux
have you tried? Other
Dietitian/Nutritionist Notes:
Food Intake Please describe what and how much you ate & drink in the past 24-hours:
Breakfast ________________________________________________________________________
Snack __________________________________________________________________________
Lunch __________________________________________________________________________
Snack __________________________________________________________________________
Dinner __________________________________________________________________________
Snack(s) ________________________________________________________________________
Confidential, 4
supplements?
Do you have food If yes, please describe:
“cravings”?
Dietitian/Nutritionist Notes:
The Surgery
What is your
motivation for
having surgery now
How long have you Have you attended a seminar about the
been considering surgery?
weight loss surgery?
Describe your
dietary plan after
surgery:
What foods will you
miss the most that
you are currently
eating?
Describe the diet
that you will have to
follow prior to
surgery and for how
Confidential, 5
long.
Week 1:
What is your
understanding of Week 2:
your diet/ food
choices immediately Week 3:
following surgery?
Week 4:
What questions do
you have about what
you can and cannot
eat after surgery?
What family and Describe WHO and HOW they will support you.
friends support you
in this decision?
Explain how they will
help you.
EXERCISE
Confidential, 6
_________________________________________
Patient Signature
Confidential, 7